'Highlight' Health financing for universal health coverage in the era of shocks, monitoring risks and opportunities in Sub-Saharan Africa

新冠肺炎等传染病暴发可改变低收入和中等收入国家的卫生筹资水平和构成，为在实现全民健康覆盖方面取得进展带来风险和机遇。“新冠肺炎”的经济后果可能威胁到在资源匮乏的情况下国内筹资的可持续性，增加捐助者在预防大流行病方面的投资可能会使援助远离基本服务，并减少援助与国家系统的协调和协调。然而，事实证明，新冠肺炎等冲击也创造了机会，可以推动积极的系统变革，一些国家正在探索卫生筹资的新途径，以加强获得与CoVID相关的护理。目前尚不清楚，新冠肺炎带来的变化是否以及如何转化为全民健康覆盖(UHC)的进展。拟议的研究借鉴了世界卫生组织监测UHC进展情况的框架。该框架确定了三个监测领域：筹资安排；效率和公平的中间成果；以及普遍保健中心的服务复盖面和负担得起的医疗支出的目标。我们的研究应用这一框架评估了五个财政分权程度和收入水平不同的撒哈拉以南非洲国家在国家和国家以下各级的卫生筹资情况：坦桑尼亚、马拉维、赞比亚、塞内加尔和塞拉利昂。我们的研究描述了新冠肺炎前后卫生筹资安排的演变，以及卫生筹资的效率和公平与UHC目标之间的进展。这项研究利用了常规的家庭调查、政府和捐助者支出信息系统，以及来自世界卫生组织和经济合作与发展组织的全球数据。这项研究有六个主要目标。首先，我们将描述政府、捐赠者和家庭筹集的卫生资金水平，以及RMNCH在一段时间内相对于传染病的资金水平。这一分析将确定，与来自政府的资金相比，这种资金是更多还是更少地依赖于家庭自付的医疗保健费用，以及这种情况是否随着新冠肺炎的启动而改变。这一分析还将评估是否存在资金流出RMNCH后的新冠肺炎。第二，我们将审查卫生、农村初级保健中心和传染病援助与国家体系协调一致的趋势，以及新冠肺炎以来的任何变化。第三，我们将按来源描述国家以下各级卫生经费随时间变化的水平，以确定不同国家以下各级单位经费的时间差异。第四，我们将衡量卫生筹资的效率，即资金在不浪费的情况下按照UHC目标得到最佳使用的程度。我们将研究为什么一些国家以下单位比其他单位更有效率，以及收入、每1000人的卫生设施数量和卫生资金来源是否重要。第五，我们将评估筹资公平性：根据新生儿和五岁以下死亡率的收入水平和负担，政府和捐助者卫生资金和家庭自付捐款在国家以下单位的分配情况。第六，我们将通过评估这些变量在国家以下单位之间的关联程度，来探索效率和UHC目标之间的关系。因此，我们将测试UHC框架，并确定效率和公平是否是实现UHC进展的良好标志。这项研究将利用倒计时2030合作伙伴关系广泛传播研究结果和分析工具包，以便在冲击的背景下分析UHC的卫生筹资情况；并在撒哈拉以南非洲开展培训。我们将通过培训和与资深研究人员结对，在我们团队中的早期职业研究人员中发展技能。

Infectious disease outbreaks, such as COVID-19 can alter the levels and composition of health financing in low and middle income countries presenting risks and opportunities for progress towards universal health coverage (UHC). The economic consequences of COVID-19, can threaten the sustainability of domestic financing in low resource settings, and increased donor investment for pandemic preparedness could risk displacing aid away from essential services, and reduce the alignment and harmonisation of aid with country systems. However, shocks, such as COVID-19, have also been shown to create moments of opportunity which can drive positive system transformation, with a number of countries now exploring new avenues for health financing to enhance access to COVID related care. It is currently unclear, whether and how the changes brought about by COVID-19 have translated into universal health coverage (UHC) progress. The proposed research draws on the World Health Organization framework for monitoring progress towards UHC. The framework identifies three areas for monitoring: financing arrangements; intermediate outcomes of efficiency and equity; and UHC goals of service coverage and affordable health expenditures. Our research applies this framework to assess health financing at the national and subnational levels in five Sub-Saharan African countries with varied degrees of fiscal decentralisation and income levels: Tanzania, Malawi, Zambia, Senegal and Sierra Leone. Our research describes the evolution of health financing arrangements before and after COVID-19, and progress in relation to efficiency and equity of health financing and UHC goals. This research draws on routine household surveys, government and donor expenditure information systems, and global data from the World Health Organzaition and the Organisation for Economic Cooperation and Development. The research has six main objectives. First, we will describe levels of health funding raised by government, donors and households, and the level of RMNCH funding relative to infectious diseases over time. This analysis will determine whether this funding is more or less reliant on household out-of-pocket payments for health care as compared to funding from government and if this has changed with the onset of COVID-19. This analysis will also assess whether there is displacement of funds away from RMNCH post COVID-19. Second, we will examine trends in the alignment and harmonisation of aid for health, RMNCH and infectious diseases with country systems and any changes since COVID-19. Third, we will describe the levels of subnational health funding by source over time to identify temporal variation in funding across subnational units. Forth, we will measure the efficiency of health financing, the degree to which funds are optimally used in terms of UHC goals, without wastage. We will examine why some subnational units are more efficient than others, and whether income, the number of health facilities per 1000 population and sources of health funding matter. Fifth, we will assess financing equity: the distribution of government and donor health funding and household out of pocket payment contributions across subnational units in relation to the income level and burden of neonatal and under five mortality. Sixth, we will explore the relationship between efficiency and UHC goals, by assessing the level of association between these variables across subnational units. We will thus test the UHC framework, and determine whether efficiency and equity are good markers of progress towards UHC. The research will use the Countdown2030 partnership to widely disseminate findings, analytical toolkits for analysing health financing for UHC in the context of shocks; and undertake training within Sub-Saharan Africa. We will develop skills among early career researchers in our team, through training and pairing with senior researchers.